Clifford Gevirtz

Ultrarapid opiate detoxification: a review

PurposeThis review on ultrarapid detoxification examines the pharmacology, techniques, and efficacy of this potentially promising technique and contrasts it with conventional treatment modalities.SourceThe information found here is derived from experiences at the Texas Tech University, government reports, and peer reviewed journals.Principal findingsIncidence and prevalence of heroin use is on the rise. Social and treatment costs suggest that this problem is staggering. Approximately 400,000 patients are enrolled in or are actively seeking methadone therapy. While many of these individuals want to undergo detoxification, traditional techniques, including methadone tapering are usually unsuccessful. The withdrawal syndrome is extremely unpleasant, may be fatal, and deters patients from completing the detoxification process. Ultrarapid detoxification entails general anesthesia in conjunction with large boluses of narcotic antagonists. This combination allows the individual to completely withdraw from the opiate without suffering the discomfort of the withdrawal syndrome. Unless performed properly, this procedure can be dangerous due to the sympathetic outflow. However, with proper support, this danger can be mitigated.ConclusionUltrarapid opiate detoxification, performed under the proper circumstances, is associated with few adverse events and is relatively comfortable for patients who seek treatment for their addition.RésuméObjectifLa présente étude portant sur la désintoxication ultrarapide revoit la pharmacologie, les techniques et l’efficacité de cette technique potentiellement prometteuse et la compare avec les modalités thérapeutiques traditionnelles.SourceNos informations sont tirées des expériences à la Texas Tech University, des rapports officiels et des journaux scientifiques. Constatations principales : L’incidence et la prévalence de l’usage d’héroïne sont en hausse. Les coûts sociaux et thérapeutiques de ce problème sont renversants. Environ 400 000 patients suivent, ou cherchent activement, un traitement à la méthadone. Beaucoup acceptent une désintoxication, mais les techniques traditionnelles, incluant l’approche dégressive avec la méthadone, sont habituellement infructueuses. Le syndrome de sevrage est très désagréable, peut être fatal et décourage les patients d’aller jusqu’au bout. La désintoxication ultrarapide nécessite une anesthésie générale conjointement avec d’importants bolus d’antagonistes narcotiques. Cette combinaison permet la suppression complète des opiacés sans subir l’inconfort du syndrome de sevrage. Si elle n’est pas réalisée correctement, cette intervention comporte un danger, lié à l’influx sympathique, danger réduit par une assistance appropriée.ConclusionLa désintoxication ultrarapide aux opiacés, réalisée dans des conditions appropriées, est associée à peu d’événements indésirables et est relativement confortable pour les patients qui cherchent un traitement à leur dépendance.

Perioperative implications of buprenorphine maintenance treatment for opioid addiction.

Prescription drug abuse, including drugs such as oxycontin, percocet, and vicodin, has reached epidemic proportions in the United States. Patients who are opiate dependent can be very demanding and challenging to care for. Chronic opiate use results in marked changes in neurophysiology and limits the effectiveness of many anesthetic medications. Buprenorphine has recently been introduced to treat opiate abuse, and it requires substantial change in how patients are managed in the perioperative period. Buprenorphine is a semisynthetic opioid thebaine derivative with extremely high binding affinity at the m-opioid and k-opioid receptors. It was first marketed by Reckitt and Colman in the 1980s as an analgesic used to treat moderate pain, formulated as a sublingual tablet (Temgesic) and an injectable product (Buprenex) available in microgram doses. In higher dosages (current formulations are available in 2 mg and 8 mg doses), buprenorphine has the curious property of blocking other opioids from binding to the m-opioid and k-opioid receptors, preventing the addicted patient, who is maintained on buprenorphine, from experiencing the ‘‘high’’ associated with heroin or other opioids, thus discouraging illicit opioid abuse. Buprenorphine, as

Update on the Management of Opioid-Induced Constipation

because of their wondrous ability to alleviate a wide range of ills. However, constipation, the gastrointestinal side effect of opioids, often is not addressed adequately, and patients can become so severely constipated that they consider foregoing adequate pain medication. It’s a dilemma they shouldn’t have to face. This opioid-induced constipation can be managed in many cases, and more hope is on the horizon with two classes of drugs that show much promise being considered for approval by the FDA.

Anesthesia-assisted opiate detoxification.

Over the past 5 years, there has been a marked increase in the number of heroin users. Recently, heroin overdoses seen in emergency rooms have increased markedly. There are an estimated 1.4 million heroin users in the United States, an increase of 300,000 over the past 5 years. Officials from the White House Office of Drug Policy attribute these dramatic changes to expanded drug trafficking by the Columbian drug cartels and the proliferation of purer, more potent heroin. Of all drug-related hospital emergency department episodes in 1996, 14% were heroin-related. Since 1990, the number of heroin-related emergency department episodes has increased by 107% for men and 110% for women (22,900 to 47,400 and 10,700 to 22,500, respectively). Since 1990, heroin-related emergency department episodes have almost tripled for those 35 and older, over 65% occurring among men. Also, 8 of 21 metropolitan areas experienced significant increases in heroinrelated emergency department visits in the past year (e.g., 48% in Detroit, 47% in Philadelphia, 29% in Phoenix). Typically addicts ingest heroin through snorting, smoking, or injection. Approximately 130,000 patients are enrolled in methadone maintenance programs, and an additional 250,000 are actively seeking methadone therapy. While many of these individuals want to and even try to undergo detoxification, traditional techniques, including methadone tapering, are usually unsuccessful. Conventional detoxification methods have included tapering doses of substitute agonist drugs and the gradual introduction of mu opioid receptor antagonists. The time requirement is 3 to 21 days. The “withdrawal syndrome,” consisting of abdominal cramps, craving for the drug, hypertension, tachycardia, diaphoresis, nausea and vomiting, diarrhea, and muscle and back pain, is extremely unpleasant and may rarely be fatal, and effectively deters patients from completing the detoxification process. Loimer first demonstrated that opiate detoxification could be performed entirely under general anesthesia.

Update on Treatment of Lumbar Spinal Stenosis: Part 1

The term lumbar spinal stenosis (LSS) refers to the anatomic narrowing of the spinal canal in the anterior-posterior axis. This narrowing is associated with a plethora of clinical symptoms. The prevalence of LSS is reported as five cases per 100,000 individuals, four times higher than the incidence of cervical spinal stenosis. The defining symptom of LSS is neurogenic claudication, which is a term coined by Dejerine1 in 1911 and further refined by von Gelderen2 in 1948. In his report, von Gelderen described neurogenic claudication as “localized, bony discoligamentous

Anesthesia for Opiate Detoxification and the Ibogaine Controversy

Opioid addiction is complex and difficult to treat. The terms addict and addiction, derive from the Latin legal term addictus, and describes someone who has surrendered to a debt holder for indefinite servitude until the debt is paid. Although not a slave, the addictus was expected to toil long and hard until, if ever, the debt was paid. Clearly, the metaphor is of the drug enslaving the addict and obligation is incumbent upon the medical profession to enable the addict to pay his or her debt in a compassionate manner. It is also clear that there are many pain patients who are dependent, not addicted but for whom the benefits of opiates are marginal and outweighed by risks and side-effects. These patients are also well suited for detoxification. The treatment of opiate dependence typically involves either conversion to opiate maintenance therapy either using methadone or buprenorphine or detoxification and abstinence with a long duration antagonist drug. Over the past 30 years, innovations evolved the process of detoxification. One of these innovations, variously known as rapid, ultrarapid, or anesthesia-assisted detoxification, is now practiced in many countries but remains mired in controversy.

Methadoneʼs eolR in Pain Management: New Dangers Revealed

Learning bjectives After reading this article, the practitioner should be able to:Describe the metabolic and transport factors that may account for the large variability in methadones half-life and analgesic effectiveness.Recall the relative risk of death associated with methadone versus buprenorphine.Define the dosage range of methadone that has been identified as having an increased risk of QTc prolongation.Identify three pain medications that can prolong the QTc interval.

Pain and Sleep–Treating Insomnia and Sleep Disturbances in Patients With Chronic Pain

Every night, a large proportion of patients with pain are deprived of rest, getting only a few troubled hours of shuteye. Most are chronically sleep-deprived, getting significantly less than the recommended number of hours each night. In this article, we review normal sleep architecture, the impact of chronic pain states on sleep patterns, and medicinal and behavioral interventions that should lead pain practitioners to aggressively evaluate potential benefit to their patients.

Complications Associated With Intrathecal Pumps

ment advances of the last few decades, useful in the treatment of numerous conditions that cause chronic pain. However, the advance has come at a price for some patients: Complications are distressingly frequent in intrathecal drug therapy. When these complications are successfully managed, an intrathecal delivery device (IDD) can continue to provide excellent pain relief. In contrast, poorly managed complications can lead to disaster. Complications of inthrathecal drug therapy can be divided into 3 major categories: implantation procedure-related, drug-related, and delivery device-related. Procedure-Related Complications

Opioid Rotation: Methods and Cautions

1 first explored the limitations of our knowledge of opioid rotation (OR). They defined OR as the process of switching from one opioid to another in an effort to improve the response to analgesic therapy or to reduce adverse effects. Rotation is used to address the problem of a patient’s poor responsiveness to a particular opioid despite optimal dose titration. Guidelines for OR are empirical rather than based purely on pharmacology. It starts with the selection of a safe and reasonably effective initial dose of the new opioid, followed by careful dose titration to optimize the balance between analgesia and adverse effects with an awareness of the dangers of rotating to the opioid. The selection of a starting dose must be based on an estimate of the relative potency of the existing opioid compared with the new one. Potency, which is defined as the dose required to produce a given effect, differs widely among opioids and also among individuals under varying clinical conditions. To rotate effectively from one opioid to another, the new opioid must be started at a dose that will cause neither toxicity nor the abstinence syndrome, and that will be sufficiently efficacious in that the pain is no worse than before the change. The estimate of relative potency used in calculating this starting dose has been codified with “equianalgesic dose tables,” which historically have been based on the best science available and have been used with little modification for more than 40 years. These tables, and the clinical protocols used to apply them to OR, may need revision, however, as the detailed pharmacology underlying relative potency evolves. Indications